CAPE GIRARDEAU — She couldn't cope. More than that, she couldn't feel.
The teenage girl was a victim of incest, and all that she endured, all the emotional damage that she carried, she buried.
"She just had bottled up her emotions, all this pain. She just couldn't feel anymore," said Jeff Johnston, a psychotherapist with Cape Girardeau-based Associated Counseling Services.
By the time the teen came to Johnston, she had been removed from her family and in and out of home placement. By the time she came to Johnston, she had discovered a dangerous relief.
The girl was a cutter, tearing her flesh with a paper clip or a razor blade to achieve a kind of curious release, a bloody catharsis.
"She resorted to hurting herself, so she could feel something," he said.
Johnston has worked in counseling services for nearly a quarter-century, and this cutter was the worst case of self-injurious behavior he said he's seen. He said he has seen more clients battling self-injury in recent years, most of them young, more female than male. He sees them as young as middle school, and the incidents of cutting tend to get worse as they get older.
While there are conflicting statistics on prevalence, there are signs that self-injury, or self-mutilation as it also is called, is on the rise, according to research analysis from Cornell University and the University of Rochester.
Guidance counselors and mental health specialists in Southeast Missouri say the numbers aren't epidemic but the incidents are alarming.
In her first few years as a counselor at Perry County Middle School, Barb Macke learned of a group of boys who were cutting themselves. She had never heard of such behavior, and it was terrifying.
Macke did some research and found behavioral science theories suggesting cutting might be an indicator of suicidal thoughts. The boys were recommended for counseling, and the four friends didn't appear to have any subsequent problems. It seemed more of a machismo thing, young teens trying to show how tough they were, she said.
For several years, Macke said cutting seemed to disappear from the list of adolescent problems. It has resurfaced, she said.
This year, she has worked with the parents of a sixth-grader who was cutting himself with the wire from his loose-leaf notebook. She has seen others who have cut deeper, most for similar reasons. When confronted, some have claimed their marks and scars are cat scratches.
"These are very uniform, almost parallel marks, obviously not a cat scratch," the counselor said.
After seeing a half a dozen cutters last school year, Macke said she knows of only a couple of confirmed cases at the middle school this year.
The numbers are difficult to track; there are few comprehensive studies on self-injury, and the research often is contradictory. Broad estimates indicate about 1 percent of the total U.S. population, perhaps as many as 3 million Americans, show signs of self-injurious behavior. Another study in the Journal of Clinical Psychology reported rates of 4 percent. Research suggests females are only somewhat more likely to self-injure than males, according to the Self-Injury Fact Sheet from the New York universities.
While it may seem paradoxical, cutters see self-injury as a coping mechanism — an unhealthy coping mechanism, Johnston said, but a way to relieve stress, anxiety, frustration, fear, nonetheless.
"It appears these kids have a lot of internalized emotions they haven't coped with, and they are looking to express the pain," he said.
It's often about control, mental health care professionals say. Cutters often feel like hurting themselves is one of the few actions over which they have control. Some seek to purify themselves or to re-enact a trauma.
Cutters come from all backgrounds. Ruth Ward, social worker for the Jackson School District, said she has seen the stereotypical "good student" struggling with cutting issues. What most have in common, she said, is they are looking for something.
"I think it can be a cry for help," Ward said. "I think a lot of times, if a person is a true cutter, they are doing it to get a sense of relief from the anxiety or the built-up emotions."
Johnston said some kind of dysfunction — abuse, divorce, a bitter custody battle — is a common thread among self-abusers.
Cutting, research suggests, can become addictive. As painful as it may seem to carve or mutilate the skin, cutters come to depend on the release of endorphins, clinical experts say. The progression to sharper instruments and deeper cuts becomes part of the demanding high.
"The process can be likened to that of a growing drug addiction, where at first, small amounts provide a sense of calm and well-being," says the Self-Injury Fact Sheet. "As tolerance builds, the user needs increasing amounts to achieve the same effect."
"I had a student who had scarred her body," Ward said. The teen received psychiatric help, she said, and appears to be doing better.
While there is debate in the psychiatric community, Johnston said self-injury appears to decrease suicidal thoughts and action. For most it serves as a temporary release, he said.
Although he said he hates to use the word in the context of cutting, Johnston sees some self-injury among teens almost as a fad.
"Some kids even identify around it, like it's cool to be a cutter," he said. "That's always a scary thing when you see a child falling into that category, where they feel affirmed because they are a cutter."
Ward said Jackson Middle School dealt with a copycat situation a couple of years ago, when a true cutter experiencing emotional problems was imitated by friends. On another occasion, a number of students tried cutting after reading a book detailing a young person's struggle with self-mutilation. They used the book as a manual to injure themselves.
"It was very scary," Ward said. "We had to address that with the whole group of students involved."
Johnston believes cutters, like alcoholics, are always in a state of recovery. The tendency is always there.
Johnston employs cognitive behavior therapy, helping clients recognize emotional triggers and correcting distorted forms of thinking. For many teens, particularly girls, he said journaling is an effective and positive form of coping. And he encourages self-abusers to openly express their emotions with safe people in their lives. It is important to substitute a more positive coping strategy and not just eliminate the self-injury, according to the Self-Injury Fact Sheet. Cutters will sometimes replace self-injury with other self-destructive behaviors, such as drug abuse. Anti-depressants also have been found to reduce some of the urge to self-injure, the fact sheet says.
Ultimately, there must be recognition, Johnston said.
"They have to realize this is an unhealthy behavior," he said.